Provider Demographics
NPI:1265656912
Name:JOHNSON, MIMI V (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIMI
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 MANNHEIM RD
Mailing Address - Street 2:PO BOX 239
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-1339
Mailing Address - Country:US
Mailing Address - Phone:708-544-5656
Mailing Address - Fax:
Practice Address - Street 1:235 MANNHEIM RD
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-1339
Practice Address - Country:US
Practice Address - Phone:708-544-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice